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APPLICATION FOR version <br /> FEDERAL ASSISTANCE 2. DATE SUBMITTED Applicant Identifier <br /> 7/27/04 / r <br /> 1. TYPE OF SUBMISSION: 3. DATE RECEIVED BY STATE State Application Identifier I <br /> Application Pre-application <br /> Fj Construction C Construction t DATE RECEIVED BY FEDERAL AGENCY Federal Identifler <br /> Non-Construction Non-Constnwdon <br /> 5. APPLICANT INFORMATION <br /> Legal Name: Organizational Unit <br /> nt <br /> Indian River County Board of County Commissioners Cpuanty Govemment <br /> Organizational DUNS: Division: <br /> 079-20&969 <br /> Address: Name and telephone number of person to be contacted on matters <br /> Street: involving this application (give area code) <br /> Prefix: First Name: <br /> 1840 25th Street I Louise <br /> City: Middle Name <br /> Vero Beach <br /> CounIndian River Hubbaard <br /> State: i _C O e Suffix: <br /> USAtry. Email: <br /> 286 irbadh@aol.com <br /> 6. EMPLOYER IDENTIFICATION NUMBER (EIN): Phone Number (give area code) Fax Number (give area code) <br /> 1 772-567-7790 772 567-5991 <br /> S. TYPE OF APPLICATION: 7. TYPE OF APPLICANT: (See back of form for Application Types) <br /> 1G New rFI Continuation F Revision B <br /> If Revision, enter appropriate letter(s) in box(es) <br /> See back of form for description of letters.) ❑ ❑ Other (specify) <br /> Other (specify) 9. NAME OF FEDERAL AGENCY: <br /> 10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER: 11 , DESCRIPTIVE TITLE OF APPLICANT'S PROJECT: <br /> []❑m❑❑ D Renewals <br /> TITLE (Name of Program): <br /> 12. AREAS AFFECTED BY PROJECT (Cfties, Counties, States, etc.): <br /> Indian River County <br /> 13, PROPOSED PROJECT 14. CONGRESSIONAL DISTRICTS OF: <br /> Start Date: Ending Date: a. Applicant b. Project <br /> 7/1 /05 6/30/06 15 5 <br /> 15. ESTIMATED FUNDING : 16, IS APPLICATION SUBJECT TO REVIEW BY STATE <br /> EXECUTIVE- <br /> RDER 12372 PROCESS? <br /> a. Federal a. Yes. {Q THIS PREAPPLICATION/APPLICATION WAS MADE <br /> AVAILABLE TO THE STATE EXECUTIVE ORDER 12372 <br /> b. Applicant PROCESS FOR REVIEW ON <br /> c. State DATE: <br /> d. Local UU <br /> b. No. PROGRAM IS NOT COVERED BY E. 0. 12372 <br /> e. Other OR PROGRAM HAS NOT BEEN SELECTED BY STATE <br /> -" FOR REVIEW <br /> I. Program Income ou17, IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT? <br /> g. TOTAL <br /> ❑ Yes If "Yes" attach an explanation. No <br /> 18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT, THE <br /> DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE <br /> ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED. <br /> pp. Authorized Reoresentative <br /> C�iarrtr►an <br /> Caroline iedie Name D - <br /> Last Name Suffix <br /> Ginn <br /> b. Title . Telephone Number (give area code) <br /> Chair, Board of County Commissioners 772-567-8000 Ext 1490 <br /> Signature of Aut (ized Representative I . Date Signed <br /> c.fJ fCJJill rina <br /> Previous Edition Usable tandard Form 424 (Rev.9-2003) <br /> Authorized for Local Reproduction Prescribed by OMB Circular A-102 <br />